When most people gamble, their financial gains or losses are minimal.
But as the opportunities to engage in legalized gambling increase, so too do the numbers of people who develop problems with buying lottery tickets, visiting casinos or betting on sporting events, studies have shown.
Often, these compulsive gamblers begin to feel that their lives are spinning out of control, and the cost of their addiction to society is greater than many people realize, says Dr. Marc N. Potenza '87, '93 Ph.D., '94 M.D., an assistant professor of psychiatry at the School of Medicine.
As director of the Problem Gambling Clinic, a collaboration between Yale's Department of Psychiatry and the Connecticut Mental Health Center (CMHC), Potenza is leading a research effort to better understand the causes of gambling addiction -- particularly its physical components -- and to develop more effective treatments.
At the clinic, located in the CMHC, the Yale psychiatrist and his colleagues have analyzed data on compulsive gamblers collected during calls to a telephone helpline, and are investigating possible biological and genetic causes of the problem. At the end of February, Potenza will lead a clinical trial testing the effectiveness of the drug Paxil in treating gambling addictions. The Problem Gambling Clinic is one of only four sites in the United States to participate in the international treatment study.
"Pathological gambling is an illness," says Potenza, a specialist on the disorder who also has expertise in the wider areas of addiction psychiatry, obsessive-compulsive spectrum disorders and molecular psychiatry. The term "pathological," he says, describes gamblers with the most severe form of the illness, who can be diagnosed using a number of criteria.
These symptoms are not unlike those experienced by people with drug addictions, according to Potenza. For example, pathological gamblers report an intense preoccupation with gambling and need to take part in the activity using increasing amounts of money in order to feel good, and they feel irritable or uncomfortable when they are unable to gamble. Despite repeated attempts to stop gambling, they are unable to do so, and will even return to gamble the very next day after losing money, which is called "chasing losses," he explains.
Like people dependent on drugs, pathological gamblers lie to family members and friends in order to hide their dependency, and many commit illegal acts to support their habit. They often need to be bailed out by family members, friends or other people to pay off gambling or other debts. Eventually, many pathological gamblers lose a significant relationship or job, or quit or are kicked out of school, because of their gambling problem, Potenza says.
While pathological gamblers make up only 1% to 2% of the general population -- a rate similar to the percentage of people who suffer from schizophrenia or bipolar disorder, notes Potenza -- the Yale psychiatrist believes that pathological gambling does "represent a significant public health problem." In the United States, there have been instances of child neglect and suicide by casino patrons, which appear linked to excessive gambling behavior, he says. News of these problems, he adds, has helped raise an awareness of just how severely affected by their gambling some individuals have become.
"Historically, pathological gambling was considered a sin or a vice," explains the psychiatrist, "just as substance abuse was once considered a sin or vice. Today, substance abuse is considered an illness, and there is recent data emerging that suggests that genetics also plays a role in gambling disorders. More work needs to be done in this area, and that is one of the projects with which we are now involved in our clinic."
In one study underway in the Problem Gambling Clinic, researchers are using magnetic resonance imaging to monitor the brain activity in pathological gamblers versus a control group of healthy subjects. These brain images are taken as study participants respond to different cues on a videotape, such as happy scenes, sad scenes and gambling scenes. Participants are asked to rate their urge to gamble while watching these various scenes. Their reported responses regarding their urge to gamble can then be compared with the images of their brain activity at the time of the cue.
Despite the similarities between substance abuse and gambling addictions, far less attention has been paid to the latter illness, according to Potenza, and thus, research on disordered gambling lags about 30 years behind substance-abuse research, he says.
To develop a greater understanding of the characteristics and behaviors of pathological gamblers, Potenza helped analyze information volunteered over the past year by callers to the Connecticut Council on Problem Gambling's Helpline, a 24-hour helpline serving citizens of the state and surrounding regions. The devastating effects of the illness were made clear by these callers.
On average, the helpline callers reported losing more than $50,000 over their lifetimes through gambling and were about $13,000 in debt at the time of their call, Potenza says. Eighty-four percent said that casino gambling was a problem for them, and about one out of three callers acknowledged that they had a problem with both casino and other forms of gambling (lottery, electronic betting, wagering money on sports, etc.) One out of six had filed for bankruptcy as a result of their gambling, and 80% reported feeling depressed in connection with their problem. One out of five admitted they had suicidal thoughts secondary to gambling.
Potenza and the other researchers' analysis of this data also revealed a high rate of alcohol and tobacco use among compulsive gamblers, high rates of family conflict, including divorce, and high rates of financial and occupational problems. In addition, the data showed some differences in the behaviors or patterns of male and female pathological gamblers.
For instance, the data indicate that pathological gambling is a male-dominated illness (the male to female ratio of gamblers identified via the helpline is 2 to 1), and that men experiencing problems with gambling were likely to be younger than their female counterparts. A larger proportion of female gamblers were between the ages of 45 and 64, whereas a larger proportion of male gamblers were between the ages of 18 and 34. Female callers were 10 times more likely than males to be widowed.
In addition, men and women gambled in different ways, Potenza says.
"Females appear more likely to engage in non-competitive or non-strategic gambling, such as slot machines -- over 70% of female gamblers had reports of a problem with casino slot machine gambling -- while only one out of three males reported problems with casino slots," explains the psychiatrist. Males, however, were more likely to report problems with competitive or strategic forms of gambling, such as blackjack, poker, non-casino sports gambling, and horse- and dog-racing, Potenza says. In addition, females were more likely to have credit card or credit line debts in connection with their gambling, while males were more likely to owe to bookies.
The data also suggest that women may develop gambling problems at a faster rate than men, an area that warrants further investigation, says Potenza, who is also interested in the connection between gambling and substance-abuse problems and other forms of mental illness.
While an estimated that gambling disorders cost U.S. society $5 billion a year, Potenza says that figure underestimates the true "cost" of the problem.
"That monetary figure may not accurately measure the effects the illness has on families who have been devastated by it through divorce and other hardships," he explains.
Furthermore, he says, those who appear to be at high-risk for gambling disorders include some of society's more vulnerable populations: adolescents, the elderly, and racial and ethnic minorities.
Currently, the most utilized treatment for gambling addictions is Gamblers Anonymous (GA), a peer support program similar to programs established for alcoholics and drug abusers. Yet, one study revealed that 9 out of 10 people who joined GA dropped out by the end of their first year in the program, and that most of those participants dropped out after only one or two meetings, according to Potenza.
"There's clearly a need to find better treatments," says Potenza, who will soon begin enrolling individuals in his paroxetine (Paxil) study, which is the first multicenter drug trial for pathological gambling. Paxil is a medication that has been used effectively in treating some forms of depression as well as obsessive-compulsive disorder (OCD) and social phobias. Some research suggests there may be a link between pathological gambling and OCD, Potenza says.
The Yale psychiatrist notes that some studies suggest that people have gambled since prehistoric times, and that gambling activities appear to have been part of every culture in the world. Gambling, he speculates, is probably a part of human nature. However, he notes, there is evidence that problematic gambling is on the rise as legalized gambling has become increasingly accessible, including on the Internet.
"The gambling industry is huge -- it grosses more than the movie, music and amusement park industries combined, and it's growing," comments Potenza. "There is no question that we need to advance our knowledge of the illness and ways to treat it. In the near future, I believe there will be a significant effort to have more people trained in treating gambling disorders.
"Our neuroimaging study focuses on gaining a better understanding of the urge to gamble, because the point at which people feel that urge represents a possible time for intervention," he adds. "We can go a long way toward treating the illness if we can help people before they engage in the destructive behavior, if we could target their symptoms at this early level."
Collaborating with Potenza on disordered gambling studies are Drs. Bruce Rounsaville, Bruce Wexler and Joel Gelernter; Stephanie O'Malley and John Gore, all from Yale; and Marvin A. Steinberg, executive director of the Connecticut Council on Problem Gambling.
By Susan Gonzalez
Dr. Marc N. Potenza and Marvin A. Steinberg will discuss "Problem Gambling: Addiction, Prevalence & Social Costs" at 5 p.m. on Thursday, March 2, in the Beaumont Room of the School of Medicine, 333 Cedar St. The event, sponsored by the Program for Humanities in Medicine, is free and open to the public. The Connecticut Council on Problem Gambling Helpline can be reached at 1-800-346-6238.
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